The patient must be a legal US resident. The patient must be treated as outpatient and have a valid prescription from a licensed U.S. healthcare Professional for a product that is included in the Valeant PAP. The patient must be uninsured; be denied coverage for Valeant product by their commercial insurance provider and have exhausted all appeal options; or not have coverage for the Valeant product requested through government health insurance, (i.e., Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE or other federal or state pharmacy assistance programs). Income criteria varies by product. To determine your eligibility to apply, or to view our full Eligibility Requirements please visit our website at ValeantPAP.com.

Complete the Patient Information and Insurance Information Sections on page 1.Read and sign the Patient Authorization and Certification on page 2. Have your prescriber complete pages 3 and 4 and sign Prescriber Certification on page 4.

Supply

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If applicable, attach a copy of your medical and prescription insurance cards.

Ship To

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Valeant prescription products are shipped to the Patient’s Home or Prescribing Physician’s Office. Orders for Controlled Substances and products administered by the physician will be shipped to comply with all state rules and regulations pertaining to how these items can be transported.

Note

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To determine your eligibility to apply, or to view our full Eligibility Requirements please visit our website at ValeantPAP.com. If you have questions about your eligibility or would like to speak with us about alternate funding options, please call the Valeant PAP at 833-862-VPAP (833-862-8727), 8 AM to 5 PM ET.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now.Click drug logo or drug name to start online application.

TIMOPTIC® in OCUDOSE® (timolol maleate ophthalmic solution)

Printable Application Forms Applications that patients can fill out and bring to their doctor.